Documentation of medical necessity is essential in providing
the patient with the best chance of approval from an insurance company,
according to Conal Doyle, Esq and presenter at the 2010 AOPA National Assembly
in Orlando, Fla.
“The more detailed and comprehensive the package, the better the
chance of approval,” Doyle told O&P Business News.
“It is important to anticipate the standard reasons for denial and ensure
that the package answers any questions that may arise.”
Doyle recommended including a prescription from a medical doctor with
the patient’s insurance claim along with a comprehensive prosthetic
evaluation. The prosthetic evaluation is crucial, especially when seeking more
expensive technology, such as microprocessor knees, according to Doyle.
According to the Amputee Coalition of America, insurers generally base
their denials on the grounds that the prosthetic component or prosthesis was
not medically necessary, the device was “experimental” or
“investigational” and/or the contract did not cover the recommended
“Most insurance companies require certification that an amputee is
a K3 ambulator or better before approving microprocessor technology,”
Doyle explained. “In that regard, it is also helpful to provide insurance
companies with a list of publications and/or studies that demonstrates the
effectiveness of microprocessor technology over conventional hydraulic knee
units. This will address the issue of whether such technology is
‘experimental’ or ‘investigational.’”
If the claim is still initially denied, a patient has the option to go
through the appeals process. The attorney would go over the patients’
insurance policy to determine what the appeals process requires.
“There are usually multiple levels of appeal and generally they
need to be exhausted before litigation can ensue,” Doyle said. “The
initial claims denial letter should set forth the process for filing a second
level appeal. After two appeals are exhausted, it is time to file a lawsuit
and/or contact the media. Although you can also file a complaint with the state
insurance commissioner, this is usually a fruitless process that does not get
your claim approved.”
The likelihood of the appeals process overturning a ruling varies,
according to Doyle.
“Sometimes the appeals process works, oftentimes it does not and
retaining an attorney is necessary,” Doyle said.
Interacting with insurance companies during the claims process can be a
particularly frustrating time for a patient who simply wants to receive the
coverage that they paid for, according to Doyle.
“Many insurance companies hope that unsophisticated patients do not
appeal and/or do not pursue legal action,” Doyle said.
“Unfortunately, this strategy often works because people do not understand
their legal rights or are intimidated by the appeals and litigation process.
— by Anthony Calabro
For more information:
- Amputee Coalition of America. When your insurance claim is denied.
Accessed: Aug. 17, 2010.
If practitioners can successfully follow Medicare’s requirements,
usually the commercial insurers follow suit. Today, commercial insurers are
making us justify basically every L-code that we use. We need to document why
they need a soft interface, for example. Outcomes documentation is also
necessary. You need to document that doing a certain addition code, achieved a
The insurance companies are well-versed in O&P. They want to see
copies of your notes. If you do not have well written notes that justify each
detail, you are most likely going to receive a denial. The key is medical
necessity. Why is it medically necessary for the patient? Does it reduce the
risk of a patient falling? Does it reduce their risk of ulceration because they
have a history of ulcerations?
There are devices that we order that may require four additional
features. You can not buy the device without them. They would then have four
codes that represent those features. Historically, we would just go ahead and
bill for the device. Today, if I were to bill the insurance company, I would
have to justify that the patient needs these features in order for the patient
to properly use the device.
— Dennis E. Ebbing, CPO
Prosthetics and Orthotics LLC and member, AOPA Coding Committee